Volume 10, Issue 5, February 13, 2018


CDC Science Clips: Volume 10, Issue 5, February 13, 2018

Science Clips is produced weekly to enhance awareness of emerging scientific knowledge for the public health community. Each article features an Altmetric Attention scoreExternal to track social and mainstream media mentions!

  1. Top Articles of the Week

    Selected weekly by a senior CDC scientist from the standard sections listed below.

    The names of CDC authors are indicated in bold text.
    • Chronic Diseases and Conditions
      • Transfer from paediatric to adult care for young adults with type 2 diabetes: the SEARCH for Diabetes in Youth StudyExternal
        Agarwal S, Raymond JK, Isom S, Lawrence JM, Klingensmith G, Pihoker C, Corathers S, Saydah S, D’Agostino RB, Dabelea D.
        Diabet Med. 2018 Jan 27.

        AIM: To describe factors associated with transfer from paediatric to adult care and poor glycaemic control among young adults with Type 2 diabetes, using the SEARCH for Diabetes in Youth study. METHODS: Young adults with Type 2 diabetes were included if they had a baseline SEARCH visit while in paediatric care at < 18 years and >/= 1 follow-up SEARCH visit at 18-25 years. At each visit, HbA1c , BMI, self-reported demographic and healthcare provider data were collected. Associations of demographic factors with transfer of care and poor glycaemic control (HbA1c >/= 75 mmol/mol; 9.0%) were explored with multivariable logistic regression. RESULTS: Some 182 young adults with Type 2 diabetes (36% male, 75% minority, 87% with obesity) were included. Most (n = 102, 56%) reported transfer to adult care at follow-up; a substantial proportion (n = 28, 15%) reported no care and 29% did not transfer. Duration of diabetes [odds ratio (OR) 1.4, 95% confidence interval (95% CI) 1.1, 1.8] and age at diagnosis (OR 1.8, 95% CI 1.4, 2.4) predicted leaving paediatric care. Transfer to adult or no care was associated with a higher likelihood of poor glycaemic control at follow-up (adult: OR 4.5, 95% CI 1.8, 11.2; none: OR 4.6, 95% CI 1.4, 14.6), independent of sex, age, race/ethnicity or baseline HbA1c level. CONCLUSIONS: Young adults with Type 2 diabetes exhibit worsening glycaemic control and loss to follow-up during the transfer from paediatric to adult care. Our study highlights the need for development of tailored clinical programmes and healthcare system policies to support the growing population of young adults with youth-onset Type 2 diabetes. This article is protected by copyright. All rights reserved.

      • OBJECTIVE: The objective of this study was to investigate how perceptions of weight by children themselves, parents, and health professionals influence children’s persistent attempts to lose weight. METHODS: The sample included 4,914 children aged 8 to 15 years from the 2005 to 2014 National Health and Nutrition Examination Survey (representing 20.7 million children). Data were analyzed using logistic regression models. RESULTS: About 34.2% never made an effort to lose weight, whereas 28.2% made persistent attempts to lose weight. Children’s persistent attempts to lose weight were highly related to their own BMI percentile. Children’s self-perceptions of overweight increased the odds of persistent attempts to lose weight more than sevenfold. Health professionals’ perceptions that children were overweight increased the odds of persistent attempts to lose weight almost threefold. However, parents’ perceptions of children as overweight had a relatively small though significant influence on children’s attempts to lose weight. CONCLUSIONS: As perceptions of children’s weight status play big roles in children’s attempts to lose weight, interventions focusing on increasing accuracy of perceptions may help promote healthy weight loss efforts. Although parents are key agents in controlling their children’s weight gain, especially among minority school-aged children, the study findings also emphasize the greater importance of health professionals on children’s attempts to lose weight across different racial/ethnic groups.

    • Communicable Diseases
      • Black/African American (black) women comprised 59% of women living with HIV at the end of 2014 and 61% of HIV diagnoses among women in 2015. Black women living with HIV infection (BWLH) have poorer health outcomes compared with women of other races/ethnicities; social and structural determinants are often cited as barriers and facilitators of care. The objective of this qualitative review was to identify social and structural barriers and facilitators of HIV treatment and care among BWLH. The systematic review was conducted in six-stages using databases such as PubMed, PsycINFO, and Google Scholar: 1) searched for studies that enrolled BWLH published between January 2005 and December 2016, 2) excluded unpublished reports and commentaries, 3) limited the search to our primary keywords, 4) limited our search to studies that included participants living with HIV infection that were >60% black and 100% female, 5) extracted and summarized the data, and 6) conducted a contextual review to identify common themes. Of 534 studies retrieved, 16 were included in the final review. Studies focused on: ART medication adherence (n = 5), engagement/retention in care (n = 4), HIV care and treatment services (n = 3), viral suppression (n = 1), and addressing multiple HIV care outcomes (n = 3). Main barrier themes included lack of family and/or social support, poor quality HIV services, and HIV-related stigma, particularly from healthcare providers; facilitator themes included resilience, positive relationships between case management and support services, high racial consciousness, and addressing mental health. Interventions that decrease these noted barriers and strengthen facilitators may help improve care outcomes for BWLH. Also, more HIV stigma-reduction training for healthcare providers may be warranted.

      • Mumps outbreak in a highly vaccinated university-affiliated setting before and after a measles-mumps-rubella vaccination campaign – Iowa, July 2015-May 2016External
        Shah M, Quinlisk P, Weigel A, Riley J, James L, Patterson J, Hickman C, Rota PA, Stewart R, Clemmons N, Kalas N, Cardemil C.
        Clin Infect Dis. 2018 Jan 6;66(1):81-88.

        Background: In response to a mumps outbreak at the University of Iowa and surrounding community, university, state, and local health officials implemented a vaccination campaign targeting students <25 years of age with an additional dose of measles-mumps-rubella (MMR) vaccine. More than 4700 vaccine campaign doses were administered; 97% were documented third doses. We describe the epidemiology of the outbreak before and after the campaign, focusing on cases in university students. Methods: Mumps cases were identified from reportable disease databases and university health system records. Detailed information on student cases was obtained from interviews, medical chart abstractions, university and state vaccination records, and state public health laboratory results. Pre- and postcampaign incidence among students, university faculty/staff, and community members <25 vs >/=25 years old were compared using Fisher exact test. Multivariable regression modeling was performed to identify variables associated with a positive mumps polymerase chain reaction test. Results: Of 453 cases in the county, 301 (66%) occurred in university students. Student cases were primarily undergraduates (90%) and highly vaccinated (86% had 2 MMR doses, and 12% had 3 MMR doses). Fewer cases occurred in students after the campaign (75 [25%]) than before (226 [75%]). Cases in the target group (students <25 years of age) declined 9% postcampaign (P=.01). A positive mumps polymerase chain reaction test was associated with the presence of parotitis and early sample collection, and inversely associated with recent receipt of MMR vaccine. Conclusions: Following a large additional dose MMR vaccination campaign, fewer mumps cases occurred overall and in the target population.

    • Disease Reservoirs and Vectors
      • Accounting for approximately 11% of all malaria cases, the Democratic Republic of the Congo (DRC) is central to malaria elimination efforts. To support vector control interventions in DRC, we characterized the dynamics and impact of insecticide resistance in major malaria vectors in 2015. High Plasmodium infection rates were recorded in Anopheles gambiae and Anopheles funestus, with Plasmodium falciparum predominant over Plasmodium malariae. Both mosquito species exhibited high and multiple resistance to major public health insecticide classes. The extremely high resistance to permethrin and DDT (dichlorodiphenyltrichloroethane) in An. gambiae (low mortalities after 6 hours exposure) is worrisome, and is supported by a reduced insecticidal effect of bed nets against both mosquito species in laboratory tests. Metabolic and target site insensitivity mechanisms are driving this resistance in An. gambiae, but only the former was observed in An. funestus. These findings highlight the urgent need for actions to prolong the effectiveness of insecticide-based interventions in DRC.

    • Drug Safety
    • Food Safety
      • World Health Organization (WHO) guidelines on use of medically important antimicrobials in food-producing animalsExternal
        Aidara-Kane A, Angulo FJ, Conly JM, Minato Y, Silbergeld EK, McEwen SA, Collignon PJ.
        Antimicrob Resist Infect Control. 2018 ;7:7.

        Background: Antimicrobial use in food-producing animals selects for antimicrobial resistance that can be transmitted to humans via food or other transmission routes. The World Health Organization (WHO) in 2005 ranked the medical importance of antimicrobials used in humans. In late 2017, to preserve the effectiveness of medically important antimicrobials for humans, WHO released guidelines on use of antimicrobials in food-producing animals that incorporated the latest WHO rankings. Methods: WHO commissioned systematic reviews and literature reviews, and convened a Guideline Development Group (GDG) of external experts free of unacceptable conflicts-of-interest. The GDG assessed the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, and formulated recommendations using a structured evidence-to-decision approach that considered the balance of benefits and harms, feasibility, resource implications, and impact on equity. The resulting guidelines were peer-reviewed by an independent External Review Group and approved by the WHO Guidelines Review Committee. Results: These guidelines recommend reductions in the overall use of medically important antimicrobials in food-producing animals, including complete restriction of use of antimicrobials for growth promotion and for disease prevention (i.e., in healthy animals considered at risk of infection). These guidelines also recommend that antimicrobials identified as critically important for humans not be used in food-producing animals for treatment or disease control unless susceptibility testing demonstrates the drug to be the only treatment option. Conclusions: To preserve the effectiveness of medically important antimicrobials, veterinarians, farmers, regulatory agencies, and all other stakeholders are urged to adopt these recommendations and work towards implementation of these guidelines.

    • Mining
      • Time domain and frequency domain deterministic channel modeling for tunnel/mining environmentsExternal
        Zhou C, Jacksha R, Yan L, Reyes M, Kovalchik P.
        Prog Electromagn Res C. 2017 ;79:209-223.

        Understanding wireless channels in complex mining environments is critical for designing optimized wireless systems operated in these environments. In this paper, we propose two physicsbased, deterministic ultra-wideband (UWB) channel models for characterizing wireless channels in mining/tunnel environments one in the time domain and the other in the frequency domain. For the time domain model, a general Channel Impulse Response (CIR) is derived and the result is expressed in the classic UWB tapped delay line model. The derived time domain channel model takes into account major propagation controlling factors including tunnel or entry dimensions, frequency, polarization, electrical properties of the four tunnel walls, and transmitter and receiver locations. For the frequency domain model, a complex channel transfer function is derived analytically. Based on the proposed physics-based deterministic channel models, channel parameters such as delay spread, multipath component number, and angular spread are analyzed. It is found that, despite the presence of heavy multipath, both channel delay spread and angular spread for tunnel environments are relatively smaller compared to that of typical indoor environments. The results and findings in this paper have application in the design and deployment of wireless systems in underground mining environments. 2017, Electromagnetics Academy. All rights reserved.

    • Zoonotic and Vectorborne Diseases
      • [No abstract]

      • The Zika Contraception Access Network: a feasibility programme to increase access to contraception in Puerto Rico during the 2016-17 Zika virus outbreakExternal
        Lathrop E, Romero L, Hurst S, Bracero N, Zapata LB, Frey MT, Rivera MI, Berry-Bibee EN, Honein MA, Monroe J, Jamieson DJ.
        Lancet Public Health. 2018 Jan 19.

        BACKGROUND: Prevention of unintended pregnancy is a primary strategy to reduce adverse pregnancy and birth outcomes related to Zika virus infection. The Zika Contraception Access Network (Z-CAN) aimed to build a network of health-care providers offering client-centred contraceptive counselling and the full range of reversible contraception at no cost to women in Puerto Rico who chose to prevent pregnancy during the 2016-17 Zika virus outbreak. Here, we describe the Z-CAN programme design, implementation activities, and baseline characteristics of the first 21 124 participants. METHODS: Z-CAN was developed by establishing partnerships between federal agencies, territorial health agencies, private corporations, and domestic philanthropic and non-profit organisations in the continental USA and Puerto Rico. Private donations to the National Foundation for the Centers for Disease Control and Prevention (CDCF) secured a supply of reversible contraceptive methods (including long-acting reversible contraception), made available to non-sterilised women of reproductive age at no cost through provider reimbursements and infrastructure supported by the CDCF. To build capacity in contraception service provision, doctors and clinic staff from all public health regions and nearly all municipalities in Puerto Rico were recruited into the programme. All providers completed 1 day of comprehensive training in contraception knowledge, counselling, and initiation and management, including the insertion and removal of long-acting reversible contraceptives (LARCs). Z-CAN was announced through health-care providers, word of mouth, and a health education campaign. Descriptive characteristics of programme providers and participants were recorded, and we estimated the factors associated with choosing and receiving a LARC method. As part of a Z-CAN programme monitoring plan, participants were invited to complete a patient satisfaction survey about whether they had obtained free, same-day access to their chosen contraceptive method after receiving comprehensive counselling, their perception of the quality of care they had received, and their satisfaction with their chosen method and services. FINDINGS: Between May 4, 2016, and Aug 15, 2017, 153 providers in the Z-CAN programme provided services to 21 124 women. 20 110 (95%) women received same-day provision of a reversible contraceptive method. Whereas only 767 (4%) women had used a LARC method before Z-CAN, 14 259 (68%) chose and received a LARC method at their initial visit. Of the women who received a LARC method, 10 808 (76%) women had used no method or a least effective method of contraception (ie, condoms or withdrawal) before their Z-CAN visit. Of the 3489 women who participated in a patient satisfaction survey, 3068 (93%) of 3294 women were very satisfied with the services received, and 3216 (93%) of 3478 women reported receiving the method that they were most interested in after receiving counselling. 2382 (78%) of 3040 women rated their care as excellent or very good. INTERPRETATION: Z-CAN was designed as a short-term response for rapid implementation of reversible contraceptive services in a complex emergency setting in Puerto Rico and has served more than 21 000 women. This model could be replicated or adapted as part of future emergency preparedness and response efforts. FUNDING: National Foundation for the Centers for Disease Control and Prevention.

  2. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Chronic Diseases and Conditions
      1. Trends in type 2 diabetes detection among adults in the USA, 1999-2014External
        Geiss LS, Bullard KM, Brinks R, Hoyer A, Gregg EW.
        BMJ Open Diabetes Res Care. 2018 ;6(1):e000487.

        Objective: To examine recent trends in type 2 diabetes detection among adults in the USA. Research design and methods: We used data from the 1999-2014 National Health and Nutrition Examination Surveys on non-pregnant adults (aged >/=18 years) not reporting a diagnosis of diabetes (n=16 644 participants, averaging about 2000 for each 2-year cycle). We defined undiagnosed diabetes as a fasting plasma glucose >/=126 mg/dL or a hemoglobin A1c >/=6.5% (48 mmol/mol). We measured case detection as the probability of finding undiagnosed type 2 diabetes among the population without diagnosed diabetes. Linear regression models were used to examine trends overall and by sociodemographic characteristics (ie, age, gender, race/ethnicity, education, poverty-income ratio (PIR)). Results: Age-standardized probability of finding undiagnosed type 2 diabetes was 3.0% (95% CI 2.1% to 4.2%) during 1999-2000 and 2.8% (2.2%-3.6%) during 2013-2014 (P for trend=0.52). Probability increased among Mexican-Americans (P for trend=0.01) but decreased among adults aged 65 years or older (P for trend=0.04), non-Hispanic (NH) white (P for trend=0.02), and adults in the highest PIR tertile (P for trend=0.047). For all other sociodemographic groups, no significant trends were detected. Conclusions: We found little evidence of increased detection of undiagnosed type 2 diabetes among adults in the USA during the past 15 years. Although improvements were seen among NH white, older, and wealthy adults, these improvements were not large. As the scope of primary prevention efforts increases, case detection may improve.

      2. [No abstract]

      3. PURPOSE: To our knowledge it is unknown whether decreases in the prevalence of prostate specific antigen screening and prostate cancer incidence rates following the USPSTF (United States Preventive Services Task Force) recommendations against routine prostate specific antigen screening are similar across socioeconomic groups and United States census regions. MATERIALS AND METHODS: We analyzed incidence rates and prostate specific antigen screening prevalence by age, race/ethnicity, disease stage, United States region and area level socioeconomic status. Annual percent changes were examined for changes in rates with time. The predicted marginal probability and 95% CIs were calculated to estimate changes in prostate specific antigen screening. RESULTS: Incidence rates in men 50 years old or older decreased in all race/ethnic, regional and socioeconomic status groups. From 2007 to 2013 the overall incidence rates for localized cancer significantly decreased 7.5% per year (95% CI -10.5–4.4) at ages 50 to 74 years and 11.1% per year (95% CI -14.1–8.1) at ages 75 years or greater. In contrast, the incidence of distant stage cancer significantly increased 1.4% per year (95% CI 0.3-2.5) from 2008 to 2013 at ages 50 to 74 years but stabilized from 2011 to 2013 at ages 75 years or greater at 5.1% per year (95% CI -3.4-14.4). Distant stage disease rates increased with increasing poverty level at ages 50 to 74 years but not at 75 years or greater. CONCLUSIONS: The prostate cancer incidence of early stage disease decreased in men 50 years old or older while the rate of distant stage disease slightly increased in men 50 to 74 years old following USPSTF recommendations against routine prostate specific antigen screening. Further studies with additional years of data are needed to substantiate our findings and monitor the effects of the late stage disease increase on prostate cancer mortality rates.

      4. Communicating with daughters about familial risk of breast cancer: Individual, family, and provider influences on women’s knowledge of cancer riskExternal
        Peipins LA, Rodriguez JL, Hawkins NA, Soman A, White MC, Hodgson ME, DeRoo LA, Sandler DP.
        J Womens Health (Larchmt). 2018 Jan 29.

        INTRODUCTION: Women facing complex and uncertain situations such as cancer in their families may seek information from a variety of sources to gain knowledge about cancer risk and reduce uncertainty. We describe and assess the relative importance of information sources about familial breast cancer at the individual, family, and healthcare provider levels influencing women’s reporting they had enough information to speak with daughters about breast cancer. This outcome we refer to as being informed about breast cancer. MATERIALS AND METHODS: Sister Study participants, a cohort of women with a family history of breast cancer, were surveyed on family cancer history, family communication, social support, and interactions with healthcare providers (n = 11,766). Adjusted percentages and 95% confidence intervals for being informed about breast cancer versus not being informed were computed for individual-, family-, and provider-level characteristics in three steps using multivariate logistic regression models. RESULTS: We found 65% of women reported being informed about breast cancer while 35% did not. Having a trusted person with whom to discuss cancer concerns, having a lower versus higher perceived risk of breast cancer, having undergone genetic counseling, and being satisfied with physician discussions about breast cancer in their families were predictors of being informed about breast cancer. CONCLUSIONS: Although acquiring objective risk information, such as through genetic counseling, may contribute to a basic level of understanding, communication with providers and within other trusted relationships appears to be an essential component in women’s reporting they had all the information they need to talk with their daughters about breast cancer.

    • Communicable Diseases
      1. Developing FAITHH: Methods to develop a faith-based HIV stigma-reduction intervention in the rural southExternal
        Bradley EL, Sutton MY, Cooks E, Washington-Ball B, Gaul Z, Gaskins S, Payne-Foster P.
        Health Promot Pract. 2018 Jan 1:1524839917754044.

        Human immunodeficiency virus (HIV) disproportionately affects Blacks/African Americans, particularly those residing in the southern United States. HIV-related stigma adversely affects strategies to successfully engage people in HIV education, prevention, and care. Interventions targeting stigma reduction are vital as additional tools to move toward improved outcomes with HIV prevention and care, consistent with national goals. Faith institutions in the South have been understudied as partners in HIV stigma-reduction efforts, and some at-risk, Black/African American communities are involved with southern faith institutions. We describe the collaborative effort with rural, southern faith leaders from various denominations to develop and pilot test Project Faith-based Anti-stigma Initiative Towards Healing HIV/AIDS (FAITHH), an HIV stigma-reduction intervention that built on strategies previously used with other nonrural, Black/African American faith communities. The eight-module intervention included educational materials, myth-busting exercises to increase accurate HIV knowledge, role-playing, activities to confront stigma, and opportunities to develop and practice delivering a sermon about HIV that included scripture-based content and guidance. Engaging faith leaders facilitated the successful tailoring of the intervention, and congregation members were willing participants in the research process in support of increased HIV awareness, prevention, and care.

      2. Age cohort differences in sexual behaviors among black men who have sex with men and womenExternal
        Dangerfield DT, Harawa NT, Fernandez MI, Hosek S, Lauby J, Joseph H, Frank HG, Bluthenthal RN.
        J Sex Res. 2018 Jan 29:1-10.

        Little attention has focused on generational or age-related differences in human immunodeficiency virus/sexually transmitted infection (HIV/STI) risk behaviors among Black men who have sex with men and women (BMSMW). We examined sexual risk behaviors between BMSMW ages 40 and under compared to over age 40. Analysis was conducted using Centers for Disease Control and Prevention (CDC)-sponsored intervention data among BMSMW in Los Angeles, Chicago, and Philadelphia (n = 546). Pearson’s chi-square tests were conducted to evaluate associations between age groups and behavioral outcomes. Logistic regression was used to evaluate the odds of behavioral outcomes by age group, adjusting for sexual orientation and study location, within strata of HIV status. HIV-positive BMSMW over age 40 had 62% reduced odds of having a nonmain female partner of HIV-negative or unknown status compared to those ages 40 and under (adjusted odds ratio [AOR] 0.38, 95% confidence interval [CI] = 0.15, 0.95). Among HIV-negative BMSMW, the older cohort was associated with greater odds of having condomless insertive anal intercourse (IAI) with most recent main male partner (AOR 2.44, 95% CI = 1.12, 5.32) and having a concurrent partnership while with their recent main female partner (AOR = 2.6, 95% CI = 1.10, 4.67). For both groups, odds of engaging in certain risk behaviors increased with increasing age. Prevention efforts should consider generational differences and age in HIV risks among BMSMW.

      3. Differences between U.S.-born and non-U.S.-born black adults reported with diagnosed HIV infection: United States, 2008-2014External
        Demeke HB, Johnson AS, Wu B, Nwangwu-Ike N, King H, Dean HD.
        J Immigr Minor Health. 2018 Jan 27.

        Despite improvements in its treatment, HIV infection continues to affect Blacks disproportionally. Using National HIV Surveillance System data from 50 U.S. states and the District of Columbia, we examined demographic and epidemiologic differences between U.S.-born and non-U.S.-born Black adults. Of 110,452 Black adults reported with diagnosed HIV during 2008-2014 with complete country of birth information, 11.1% were non-U.S.-born. Non-U.S.-born were more likely to be older, female, have HIV infection attributed to heterosexual contact, have been diagnosed late, and live in the northeastern U.S. region. During 2014, the HIV diagnosis rate among African-born Black females was 1.4 times the rate of U.S.-born Black males, 2 times the rate of African-born Black males, and 5.3 times the rate of U.S.-born Black females. We elucidate the differences between U.S.-born and non-U.S.-born Blacks on which to base culturally appropriate HIV-prevention programs and policies.

      4. Long-term cognitive impairment after hospitalization for community-acquired pneumonia: A prospective cohort studyExternal
        Girard TD, Self WH, Edwards KM, Grijalva CG, Zhu Y, Williams DJ, Jain S, Jackson JC.
        J Gen Intern Med. 2018 Jan 26.

        BACKGROUND: Recent studies suggest older patients hospitalized for community-acquired pneumonia are at risk for new-onset cognitive impairment. The characteristics of long-term cognitive impairment after pneumonia, however, have not been elucidated. OBJECTIVE: To characterize long-term cognitive impairment among adults of all ages hospitalized for community-acquired pneumonia. DESIGN: Prospective cohort study. PARTICIPANTS: Adults without severe preexisting cognitive impairment who were hospitalized with community-acquired pneumonia. MAIN MEASURES: At enrollment, we estimated baseline cognitive function with the Short Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). At 2- and 12-month follow-up, we assessed cognition using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and tests of executive function, diagnosing cognitive impairment when results were >/= 1.5 standard deviations below published age-adjusted means for the general population. We also identified subtypes of mild cognitive impairment using standard definitions. KEY RESULTS: We assessed 58 (73%) of 80 patients who survived to 2-month follow-up and 57 (77%) of 74 who survived to 12-month follow-up. The median [range] age of survivors tested was 57 [19-97] years. Only 8 (12%) had evidence of mild cognitive impairment at baseline according to the Short IQCODE, but 21 (38%) at 2 months and 17 (30%) at 12 months had mild cognitive impairment per the RBANS. Moderate-to-severe cognitive impairment was common among adults >/= 65 years [4/13 (31%) and 5/13 (38%) at 2 and 12 months, respectively] but also affected many of those < 65 years [10/43 (23%) and 8/43 (19%) at 2 and 12 months, respectively]. Deficits were most often noted in visuospatial function, attention, and memory. CONCLUSIONS: A year after hospitalization for community-acquired pneumonia, moderate-to-severe impairment in multiple cognitive domains affected one-third of patients >/= 65 years old and 20% of younger patients, and another third of survivors had mild cognitive impairment.

      5. Notes from the field: Public health response to a human immunodeficiency virus outbreak associated with unsafe injection practices – Roka Commune, Cambodia, 2016External
        Ijeoma UC, Sansam S, Srun S, Vannara H, Sanith S, Sopheap T, Newman RD, Gadde R, Dejana S, Hassani AS, Ly V, Drammeh B, De A, Byrd J, Bock N.
        MMWR Morb Mortal Wkly Rep. 2018 Feb 2;67(4):135-136.

        [No abstract]

      6. Virologic outcome among patients receiving antiretroviral therapy at five hospitals in HaitiExternal
        Jean Louis F, Buteau J, Francois K, Hulland E, Domercant JW, Yang C, Boncy J, Burris R, Pelletier V, Wagar N, Deyde V, Lowrance DW, Charles M.
        PLoS One. 2018 ;13(1):e0192077.

        INTRODUCTION: Viral load (VL) assessment is the preferred method for diagnosing and confirming virologic failure for patients on antiretroviral therapy (ART). We conducted a retrospective cross-sectional study to evaluate the virologic suppression rate among patients on ART for >/=6 months in five hospitals around Port-au-Prince, Haiti. METHODS: Plasma VL was measured and patients with VL <1,000 copies/mL were defined as virologically suppressed. A second VL test was performed within at least six months of the first test. Factors associated with virologic suppression were analyzed using logistic regression models accounting for site-level clustering using complex survey procedures. RESULTS: Data were analyzed for 2,313 patients on ART for six months or longer between July 2013 and February 2015. Among them, 1,563 (67.6%) achieved virologic suppression at the first VL test. A second VL test was performed within at least six months for 718 (31.0%) of the patients. Of the 459 patients with an initial HIV-1 RNA <1,000 copies/mL who had a second VL performed, 394 (85.8%) maintained virologic suppression. Virologic suppression was negatively associated with male gender (adjusted odds ratio [aOR]: 0.80, 95% CI: 0.74-0.0.86), 23 to 35 months on ART (aOR:0.72[0.54-0.96]), baseline CD4 counts of 201-500 cells/mm3 and 200 cells/mm3 or lower (aORs: 0.77 [0.62-0.95] and 0.80 [0.66-0.98], respectively), poor adherence (aOR: 0.69 [0.59-0.81]), and TB co-infection (aOR: 0.73 [0.55-0.97]). CONCLUSIONS: This study showed that over two-thirds of the patients in this evaluation achieved virologic suppression after >/= six months on ART and the majority of them remained suppressed. These results reinforce the importance of expanding access to HIV-1 viral load testing in Haiti for monitoring ART outcomes.

      7. Patient and provider perspectives inform an intervention to improve linkage to care for HIV patients in UkraineExternal
        Kiriazova T, Postnov O, Bingham T, Myers J, Flanigan T, Vitek C, Neduzhko O.
        BMC Health Serv Res. 2018 Jan 30;18(1):58.

        BACKGROUND: Engagement with HIV medical care is critical to successful HIV treatment and prevention efforts. However, in Ukraine, delays in the timely initiation of HIV treatment hamper viral suppression. By January 01, 2016, only 126,604 (57.5%) of the estimated 220,000 people living with HIV (PLWH) had registered for HIV care, and most (55.1%) of those who registered for HIV care in 2015 did that at a late stage of infection. In the US, Anti-Retroviral Treatment and Access to Services (ARTAS) intervention successfully linked newly diagnosed PLWH to HIV services using strengths-based case management with a linkage coordinator. To tailor the ARTAS intervention for Ukraine, we conducted a qualitative study with patients and providers to understand barriers and facilitators that influence linkage to HIV care. METHODS: During September-October 2014, we conducted 20 in-depth interviews with HIV-positive patients and two focus groups with physicians in infectious disease, sexually transmitted infection (STI), and addiction clinics in Dnipropetrovsk Region of Ukraine. Interviews and focus groups were audio-recorded and transcribed verbatim. We translated illustrative quotes into English. We used thematic analysis for the data analysis. RESULTS: Participants (20 patients and 14 physicians) identified multiple, mostly individual-level factors influencing HIV care initiation. Key barriers included lack of HIV knowledge, non-acceptance of HIV diagnosis, fear of HIV disclosure, lack of psychological support from health providers, and HIV stigma in community. Responsibility for one’s health, health deterioration, and supportive provider communication were reported as facilitators to linkage to care. Expected benefits from the case management intervention included psychological support, HIV education, and help with navigating the segmented health system. CONCLUSIONS: The findings from the study will be used to optimize the ARTAS for the Ukrainian context. Our findings can also support future linkage-to-care strategies in other countries of Eastern Europe and Central Asia.

      8. Spatial clusters of latent tuberculous infection, Connecticut, 2010-2014External
        Mullins J, Lobato MN, Bemis K, Sosa L.
        Int J Tuberc Lung Dis. 2018 ;22(2):165-170.

        SETTING: In the United States, tuberculosis (TB) control is increasingly focusing on the identification of persons with latent tuberculous infection (LTBI). OBJECTIVE : To characterize the local epidemiology of LTBI in Connecticut, USA. METHODS : We used spatial analyses 1) to identify census tract-level clusters of reported LTBI and TB disease in Connecticut, 2) to compare persons and populations in clusters with those not in clusters, and 3) to compare persons with LTBI to those with TB disease. RESULT S : Significant census tract-level spatial clusters of LTBI and TB disease were identified. Compared with persons with LTBI in non-clustered census tracts, those in clustered census tracts were more likely to be foreignborn and less likely to be of white non-Hispanic ethnicity. Populations in census tract clusters of high LTBI prevalence had greater crowding, persons living in poverty, and persons lacking health care insurance than populations not in clustered census tracts. Persons with LTBI were less likely than those with TB disease to be of Asian ethnicity, and persons with LTBI were more likely than those with TB disease to reside in a clustered census tract. CONCLUS IONS : Characterizing fine-scale populations at risk for LTBI supports effective and culturally accessible screening and treatment programs.

      9. Healthcare-associated norovirus outbreaks increase later but have a more pronounced seasonality than nonhealthcare norovirus outbreaks. Healthcare-associated norovirus outbreaks had higher correlation with Google Trends activity than nonhealthcare outbreaks (R2=0.68 vs 0.39). Google Trends data may have the potential to supplement existing norovirus surveillance due to its real-time availability. Infect Control Hosp Epidemiol 2018;1-4.

      10. Acute liver failure in an adolescent male induced by human herpesvirus 6 (HHV-6): A case report with literature reviewExternal
        Szewc AM, Taylor S, Cage GD, Jacobsen J, Bulut OP, de Mello DE.
        Lab Med. 2018 Jan 30.

        A previously healthy 11-year-old Caucasian boy presented with a 2-week history of nonspecific symptoms of nausea and nonbilious, nonbloody emesis. He developed significant jaundice and hepatic encephalopathy within 1 week of beginning symptoms and was discovered to have fulminant liver failure. Extensive work-ups for underlying etiologies included serologic evaluation for underlying chronic liver diseases, toxicology screening, inborn errors of metabolism, and infectious diseases. The results of the entire assessment were negative except for human herpesvirus 6B, which was detected in the liver by quantitative real-time polymerase chain reaction and immunohistochemical analysis. The patient underwent ABO-compatible liver transplantation and has had clinically stable health, with no evidence to date of complications associated with HHV-6 or other members of the herpesvirus family.

      11. Loss to follow-up before and after initiation of antiretroviral therapy in HIV facilities in Lilongwe, MalawiExternal
        Tweya H, Oboho IK, Gugsa ST, Phiri S, Rambiki E, Banda R, Mwafilaso J, Munthali C, Gupta S, Bateganya M, Maida A.
        PLoS One. 2018 ;13(1):e0188488.

        INTRODUCTION: Although several studies have explored factors associated with loss to follow-up (LTFU) from HIV care, there remains a gap in understanding how these factors vary by setting, volume of patient and patients’ demographic and clinical characteristics. We determined rates and factors associated with LTFU in HIV care Lilongwe, Malawi. METHODS: We conducted a retrospective cohort study of HIV-infected individuals aged 15 years or older at the time of registration for HIV care in 12 ART facilities, between April 2012 and March 2013. HIV-positive individuals who had not started ART (pre-ART patients) were clinically assessed to determine ART eligibility at registration and during clinic follow-up visits. ART-eligible patients were initiated on triple antiretroviral combination. Study data were abstracted from patients’ cards, facility ART registers or electronic medical record system from the date of registration for HIV care to a maximum follow-up period of 24 months. Descriptive statistics were undertaken to summarize characteristics of the study patients. Separate univariable and multivariable poisson regression models were used to explore factors associated with LTFU in pre-ART and ART care. RESULTS: A total of 10,812 HIV-infected individuals registered for HIV care. Of these patients, 1,907 (18%) and 8,905 (82%) enrolled in pre-ART and ART care, respectively. Of the 1,907 pre-ART patients, 490 (26%) subsequently initiated ART and were included in both the pre-ART and ART analyses. The LTFU rates among patients in pre-ART and ART care were 48 and 26 per 100 person-years, respectively. Of the 9,105 ART patients with reasons for starting ART, 2,451 (27%) were initiated on ART because of pregnancy or breastfeeding (Option B+) status. Multivariable analysis showed that being >/=35 years and female were associated with decreased risk of LTFU in the pre-ART and ART phases of HIV care. However, being in WHO clinical stage 3 (adjusted risk ratio (aRR) 1.35, 95% confidence interval (CI): 1.20-1.51) and stage 4 (aRR 1.87, 95% CI: 1.62-2.18), body mass index </= 18.4 (aRR 1.24, 95% CI: 1.11-1.39) at ART initiation, poor adherence to clinic appointments (aRR 4.55, 95% CI: 4.16-4.97) and receiving HIV care in rural facilities (aRR 2.32, 95% CI: 1.94-2.87) were associated with increased risk of LTFU among ART patients. Being re-initiated on ART once (aRR 0.20, 95% CI: 0.17-0.22), more than once (aRR 0.06, 95% CI: 0.05-0.07), and being enrolled at a low-volume facility (aRR 0.25, 95% CI: 0.20-0.30) were associated with decreased risk of LTFU from ART care. CONCLUSION: A sizeable proportion of ART LTFU occurred among women enrolled during pregnancy or breast-feeding. Non- compliance to clinic and receiving ART in a rural facility or high-volume facility were associated with increased risk of LTFU from ART care. Developing effective interventions that target high-risk subgroups and contexts may help reduce LTFU from HIV care.

      12. Active Ebola virus replication and heterogeneous evolutionary rates in EVD survivorsExternal
        Whitmer SL, Ladner JT, Wiley MR, Patel K, Dudas G, Rambaut A, Sahr F, Prieto K, Shepard SS, Carmody E, Knust B, Naidoo D, Deen G, Formenty P, Nichol ST, Palacios G, Stroher U.
        Cell Rep. 2018 Jan 30;22(5):1159-1168.

        Following cessation of continuous Ebola virus (EBOV) transmission within Western Africa, sporadic EBOV disease (EVD) cases continued to re-emerge beyond the viral incubation period. Epidemiological and genomic evidence strongly suggests that this represented transmission from EVD survivors. To investigate whether persistent infections are characterized by ongoing viral replication, we sequenced EBOV from the semen of nine EVD survivors and a subset of corresponding acute specimens. EBOV evolutionary rates during persistence were either similar to or reduced relative to acute infection rates. Active EBOV replication/transcription continued during convalescence, but decreased over time, consistent with viral persistence rather than viral latency. Patterns of genetic divergence suggest a moderate relaxation of selective constraints within the sGP carboxy-terminal tail during persistent infections, but do not support widespread diversifying selection. Altogether, our data illustrate that EBOV persistence in semen, urine, and aqueous humor is not a quiescent or latent infection.

    • Disease Reservoirs and Vectors
      1. African lineage Brucella melitensis isolates from Omani livestockExternal
        Foster JT, Walker FM, Rannals BD, Hussain MH, Drees KP, Tiller RV, Hoffmaster AR, Al-Rawahi A, Keim P, Saqib M.
        Front Microbiol. 2017 ;8:2702.

        Brucellosis is a common livestock disease in the Middle East and North Africa, but remains poorly described in the region both genetically and epidemiologically. Traditionally found in goats and sheep, Brucella melitensis is increasingly recognized as infecting camels. Most studies of brucellosis in camels to date have focused on serological surveys, providing only limited understanding of the molecular epidemiology of circulating strains. We genotyped B. melitensis isolates from Omani camels using whole genome SNP assays and VNTRs to provide context for regional brucellosis cases. We identified a lineage of B. melitensis circulating in camels as well as in goats, sheep, and cattle in Oman. This lineage is genetically distinct from most genotypes from the Arabian Peninsula and from isolates from much of the rest of the Middle East. We then developed diagnostic assays that rapidly identify strains from this lineage. In analyses of genotypes from throughout the region, Omani isolates were genetically most closely related to strains from brucellosis cases in humans and livestock in North Africa. Our findings suggest an African origin for B. melitensis in Oman that has likely occurred through the trade of infected livestock. Moreover, African lineages of B. melitensis appear to be undersampled and consequently are underrepresented in genetic databases for Brucella. As we begin to more fully understand global genomic diversity of B. melitensis, finding and characterizing these unique but widespread lineages is essential. We predict that increased sampling of humans and livestock in Africa will reveal little known diversity in this important zoonotic pathogen.

      2. Mammalian hosts, vectors, and bacterial pathogens in communities with and without black-tailed prairie dogs (Cynomys ludovicianus) in northwestern MexicoExternal
        Zapata-Valdes C, Avila-Flores R, Gage K, Holmes J, Montenierri J, Kosoy M, Suzan G.
        J Wildl Dis. 2018 Jan;54(1):26-33.

        The presence of keystone species can influence disease dynamics through changes in species diversity and composition of vector and host communities. In this study, we compared 1) the diversity of small mammals; 2) the prevalence, abundance, and intensity of arthropod vectors; and 3) the prevalence of Yersinia pestis, Francisella tularensis, and Bartonella spp. in vectors, between two grassland communities of northern Sonora, Mexico, one with (La Mesa [LM]) and one without (Los Fresnos [LF]) black-tailed prairie dogs ( Cynomys ludovicianus). The mammal community in LF exhibited higher species richness and diversity than LM, and species composition was different between the two communities. Flea species richness, prevalence, abundance, and intensity, were higher in LM than in LF. The most abundant fleas were Oropsylla hirsuta and Pulex simulans, and C. ludovicianus was the host with the highest flea intensity and richness. There was no serologic evidence for the presence of Y. pestis and F. tularensis in any community, but Bartonella spp. was present in 18% of the total samples. Some specificity was observed between Bartonella species, flea species, and mammal species. Although prairie dogs can indirectly affect the diversity and abundance of hosts and vectors, dynamics of vector-borne diseases at these spatial and temporal scales may be more dependent on the vector and pathogen specificity.

    • Environmental Health
      1. Results of an Arctic Council survey on water and sanitation services in the ArcticExternal
        Bressler JM, Hennessy TW.
        Int J Circumpolar Health. 2018 Dec;77(1):1421368.

        As part of a project endorsed by the Arctic Council’s Sustainable Development Working Group (SDWG), a survey was conducted to describe the current status of water, sanitation and hygiene (WASH) services in the Arctic region. The English language internet-based survey was open from April to September, 2016 and drew 142 respondents from seven Arctic nations. Respondents provided information on access to WASH services, notification requirements for water-related infectious diseases, and examples of environmental- or climate-change related events that impact the provision of WASH services. Many remote Arctic and sub-Arctic residents lack WASH services, and these disparities are often not reflected in national summary data. Environmental changes impacting WASH services were reported by respondents in every Arctic nation. Participants at an international conference co-sponsored by SDWG reviewed these results and provided suggestions for next steps to improve health of Arctic residents through improved access to water and sanitation services. Suggestions included ongoing reporting on WASH service availability in underserved populations to measure progress towards UN Sustainable Development Goal #6; evaluations of the health and economic consequences of disparities in WASH services; and Arctic-specific forums to share innovations in WASH technology, improved management and operations, and adaptation strategies for environmental or climate change.

      2. Acute illnesses and injuries related to total release foggers – 10 States, 2007-2015External
        Liu R, Alarcon WA, Calvert GM, Aubin KG, Beckman J, Cummings KR, Graham LS, Higgins SA, Mulay P, Patel K, Prado JB, Schwartz A, Stover D, Waltz J.
        MMWR Morb Mortal Wkly Rep. 2018 Feb 2;67(4):125-130.

        Total release foggers (TRFs) (also known as “bug bombs”) are pesticide products often used indoors to kill insects. After an earlier report found that TRFs pose a risk for acute illness (1), the Environmental Protection Agency required improved labels on TRFs manufactured after September 2012 (2). To examine the early impact of relabeling, the magnitude and characteristics of acute TRF-related illness were evaluated for the period 2007-2015. A total of 3,222 TRF-related illnesses were identified in 10 participating states, based on three data sources: Sentinel Event Notification System for Occupational Risk-Pesticides (SENSOR) programs, the California Department of Pesticide Regulation (CDPR) program, and poison control centers (PCCs) in Florida, Texas, and Washington. No statistically significant decline in the overall TRF-illness incidence rate was found. Failure to vacate treated premises during application was the most commonly reported cause of exposure. To reduce TRF-related illness, integrated pest management strategies (3) need to be adopted, as well as better communication about the hazards and proper uses of TRFs. Redesigning TRFs to prevent sudden, unexpected activation might also be useful.

    • Epidemiology and Surveillance
      1. Evaluating variance estimators for respondent-driven samplingExternal
        Spiller MW, Gile KJ, Handcock MS, Mar CM, Wejnert C.
        J Surv Stat Methodol. 2017 ;2017.

        [No abstract]

    • Genetics and Genomics
      1. Problems of classification in the family ParamyxoviridaeExternal
        Rima B, Collins P, Easton A, Fouchier R, Kurath G, Lamb RA, Lee B, Maisner A, Rota P, Wang LF.
        Arch Virol. 2018 Jan 25.

        A number of unassigned viruses in the family Paramyxoviridae need to be classified either as a new genus or placed into one of the seven genera currently recognized in this family. Furthermore, numerous new paramyxoviruses continue to be discovered. However, attempts at classification have highlighted the difficulties that arise by applying historic criteria or criteria based on sequence alone to the classification of the viruses in this family. While the recent taxonomic change that elevated the previous subfamily Pneumovirinae into a separate family Pneumoviridae is readily justified on the basis of RNA dependent -RNA polymerase (RdRp or L protein) sequence motifs, using RdRp sequence comparisons for assignment to lower level taxa raises problems that would require an overhaul of the current criteria for assignment into genera in the family Paramyxoviridae. Arbitrary cut off points to delineate genera and species would have to be set if classification was based on the amino acid sequence of the RdRp alone or on pairwise analysis of sequence complementarity (PASC) of all open reading frames (ORFs). While these cut-offs cannot be made consistent with the current classification in this family, resorting to genus-level demarcation criteria with additional input from the biological context may afford a way forward. Such criteria would reflect the increasingly dynamic nature of virus taxonomy even if it would require a complete revision of the current classification.

    • Health Disparities
      1. Non-Hispanic blacks/African Americans (blacks) represent 12% of the U.S. POPULATION: * However, in 2014 an estimated 43% (471,500) of persons living with diagnosed and undiagnosed human immunodeficiency virus (HIV) infection were blacks (1). In 2016, blacks accounted for 44% of all new HIV diagnoses (2). Although antiretroviral therapy (ART) prescriptions among persons in HIV care increased overall from 89% in 2009 to 94% in 2013, fewer blacks than Hispanics or Latinos (Hispanics) and non-Hispanic whites (whites) were on ART and had a suppressed viral load (<200 HIV RNA copies/mL) in their most recent viral load test result (3). Blacks also might be less likely to have sustained viral suppression over time and to experience longer periods with viral loads >1,500 HIV RNA copies/mL, a level that increases the risk for transmitting HIV (4-7). National HIV Surveillance System (NHSS) data are among those used to monitor progress toward reaching the national goal of reducing health disparities. CDC analyzed NHSS data to describe sustained viral suppression and transmission risk potential by race/ethnicity. Among 651,811 persons with HIV infection diagnosed through 2013 and who were alive through 2014 in 38 jurisdictions with complete laboratory reporting, a lower percentage of blacks had sustained viral suppression (40.8%), than had Hispanics (50.1%) and whites (56.3%). Among persons who were in care (i.e., had at least one viral load test in 2014) and had not achieved sustained viral suppression in 2014, blacks experienced longer periods (52.1% of the 12-month period) with viral loads >1,500 copies/mL, than did Hispanics (47.2%) and white (40.8%). Blacks aged 13-24 years had the lowest prevalence of sustained viral suppression, a circumstance that might increase transmission risk potential. Strengthening interventions that improve access to ART, promote adherence, and address barriers to clinical care and supportive services for all persons with diagnosed HIV infection is important for achieving the national goal of reducing health disparities.

    • Health Economics
      1. The effect of costs on Kenyan households’ demand for medical care: why time and distance matterExternal
        Kukla M, McKay N, Rheingans R, Harman J, Schumacher J, Kotloff KL, Levine MM, Breiman R, Farag T, Walker D, Nasrin D, Omore R, O’Reilly C, Mintz E.
        Health Policy Plan. 2017 Dec 1;32(10):1397-1406.

        In an environment of constrained resources, policymakers must identify solutions for financing and delivering health services that are efficient and sustainable. However, such solutions require that policymakers understand the complex interaction between household utilization patterns, factors influencing household medical decisions, and provider performance. This study examined whether and under what conditions out-of-pocket, transportation, and time costs influenced Kenyan households’ choice of medical provider for childhood diarrhoeal illnesses. It compared these decisions with the actual cost and quality of those providers to assess strategies for increasing the utilization of high quality, low-cost primary care. This study analyzed nationally-representative survey data through several multinomial nested logit models. On average, time costs accounted for the greatest share of total costs. Households spent the most time and transportation costs utilizing public care, yet were more likely to incur catastrophic time and out-of-pocket costs seeking private care for their child’s diarrhoeal illness. Out-of-pocket, transportation, and time costs influenced households’ choice of provider, though demand was cost inelastic and households were most responsive to transportation costs. Poorer households were the most responsive to changes in all cost types and most likely to self-treat or utilize informal care. Many households utilized informal care that, relative to formal care, cost the same but was of worse quality-suggesting that such households were making poor medical decisions for their children. To achieve public policy objectives, such as financial risk protection for childhood illnesses and equitable access to primary care, policymakers could focus on three areas: (1) refine financing strategies for further reducing household out-of-pocket costs; (2) reduce or subsidize time and transportation costs for households seeking public and private care; and (3) increase transparency of costs and quality to improve household decisions.

    • Immunity and Immunization
      1. Rotavirus vaccines: Effectiveness, safety, and future directionsExternal
        Burnett E, Parashar U, Tate J.
        Paediatr Drugs. 2018 Jan 31.

        Rotavirus is the leading cause of diarrheal death among children < 5 years old worldwide, estimated to have caused ~ 215,000 deaths in 2013. Prior to rotavirus vaccine implementation, > 65% of children had at least one rotavirus diarrhea illness by 5 years of age and rotavirus accounted for > 40% of all-cause diarrhea hospitalizations globally. Two live, oral rotavirus vaccines have been implemented nationally in > 100 countries since 2006 and their use has substantially reduced the burden of severe diarrheal illness in all settings. Vaccine efficacy and effectiveness estimates suggest there is a gradient in vaccine performance between low child-mortality countries (> 90%) and medium and high child-mortality countries (57-75%). Additionally, an increased risk of intussusception (~ 1-6 per 100,000 vaccinated infants) following vaccination has been documented in some countries, but this is outweighed by the large benefits of vaccination. Two additional live, oral rotavirus vaccines were recently licensed and these have improved on some programmatic limitations of earlier vaccines, such as heat stability, cost, and cold-chain footprint. Non-replicating rotavirus vaccines that are parenterally administered are in clinical testing, and these have the potential to reduce the performance differential and safety concerns associated with live oral rotavirus vaccines.

      2. Background: Recent observational studies in the United States indicated live attenuated influenza vaccine (LAIV) was less effective in children against clinical influenza infection caused by A(H1N1)pdm09 relative to inactivated influenza vaccine (IIV). During the 2013-2014 influenza season, we conducted an observational study among children aged 5-17 years to compare serologic responses to LAIV and IIV and explore factors associated with vaccine failure. Methods: One hundred and sixty-one children received one dose of trivalent IIV or quadrivalent LAIV according to parental preference. Baseline and postvaccination serum samples were tested with hemagglutination inhibition (HI) assays against vaccine reference strains. Geometric mean titers (GMT), geometric mean fold rise (GMFR), seroconversion, and seroprotection (HI titer ? 40) were used to assess response to vaccine. Active surveillance for acute respiratory illness was conducted during the influenza season and influenza cases were confirmed by reverse transcription polymerase chain reaction (RT-PCR). Logistic regression was used to examine the association between vaccine type and vaccine failure. Results: LAIV and IIV recipients were similar with respect to demographics and baseline GMT for each vaccine strain. RT-PCR confirmed influenza (vaccine failure) occurred in 8 (13%) of 62 LAIV recipients and 3 (3%) of 99 IIV recipients (p = .02). Postvaccination GMFR for A(H1N1)pdm09 was higher for IIV vs LAIV receipt (GMFR 3.3 vs. 0.8, p < .0001). Postvaccination titers against A(H1N1)pdm09 were ?40 for 91% and 44% of IIV and LAIV recipients, respectively (p < .0001). Among 13 IIV and 18 LAIV recipients with seronegative baseline titer against A(H1N1pdm09), 54% and 0% seroconverted, respectively. LAIV receipt was the only factor associated with A(H1N1)pdm09 vaccine failure in the age-adjusted multivariable model (odds ratio 4.5, 95% CI 1.1-18.2). Conclusion: Receipt of LAIV generated minimal HI antibody response in children, including among those seronegative at baseline. LAIV recipients had significant increased risk of A(H1N1)pdm09 infection compared to IIV recipients.

      3. Rotavirus strain distribution in Ghana pre- and post- rotavirus vaccine introductionExternal
        Lartey BL, Damanka S, Dennis FE, Enweronu-Laryea CC, Addo-Yobo E, Ansong D, Kwarteng-Owusu S, Sagoe KW, Mwenda JM, Diamenu SK, Narh C, Binka F, Parashar U, Lopman B, Armah GE.
        Vaccine. 2018 Jan 20.

        BACKGROUND: Ghana introduced the monovalent rotavirus vaccine (Rotarix) into its national paediatric vaccination programme in May2012. Vaccine introduction was initiated nationwide and achieved >85% coverage within a few months. Rotavirus strain distribution pre- and post-RV vaccine introduction is reported. METHODS: Stool samples were collected from diarrhoeic children <5years of age hospitalized between 2009 and 2016 at sentinel sites across Ghana and analyzed for the presence of group A rotavirus by enzyme immunoassay. Rotavirus strains were characterized by RT-PCR and sequencing. RESULTS: A total of 1363 rotavirus EIA-positive samples were subjected to molecular characterization. These were made up of 823 (60.4%) and 540 (39.6%) samples from the pre- and post-vaccine periods respectively. Rotavirus VP7 genotypes G1, G2 and G3, and VP4 genotypes P[6] and P[8] constituted more than 65% of circulating G and P types in the pre-vaccine period. The common strains detected were G1P[8] (20%), G3P[6] (9.2%) and G2P[6] (4.9%). During the post-vaccine period, G12, G1 and G10 genotypes, constituted more than 65% of the VP7 genotypes whilst P[6] and P[8] made up more than 75% of the VP4 genotypes. The predominant circulating strains were G12P[8] (26%), G10P[6] (10%) G3P[6] (8.1%) and G1P[8] (8.0%). We also observed the emergence of the unusual rotavirus strain G9P[4] during this period. CONCLUSION: Rotavirus G1P[8], the major strain in circulation during the pre-vaccination era, was replaced by G12P[8] as the most predominant strain after vaccine introduction. This strain replacement could be temporary and unrelated to vaccine introduction since an increase in G12 was observed in countries yet to introduce the rotavirus vaccine in West Africa. A continuous surveillance programme in the post-vaccine era is necessary for the monitoring of circulating rotavirus strains and the detection of unusual/emerging genotypes.

      4. Future of human Chlamydia vaccine: Potential of self-adjuvanting biodegradable nanoparticles as safe vaccine delivery vehiclesExternal
        Sahu R, Verma R, Dixit S, Igietseme JU, Black CM, Duncan S, Singh SR, Dennis VA.
        Expert Rev Vaccines. 2018 Jan 30.

        INTRODUCTION: There is a persisting global burden and considerable public health challenge by the plethora of ocular, genital and respiratory diseases caused by members of the Gram-negative bacteria of the genus Chlamydia. The major diseases are conjunctivitis and blinding trachoma, non-gonococcal urethritis, cervicitis, pelvic inflammatory disease, ectopic pregnancy, tubal factor infertility, and interstitial pneumonia. The failures in screening and other prevention programs led to the current medical opinion that an efficacious prophylactic vaccine is the best approach to protect humans from chlamydial infections. Unfortunately, there is no human Chlamydia vaccine despite successful veterinary vaccines. A major challenge has been the effective delivery of vaccine antigens to induce safe and effective immune effectors to confer long-term protective immunity. The dawn of the era of biodegradable polymeric nanoparticles and the adjuvanted derivatives may accelerate the realization of the dream of human vaccine in the foreseeable future. Areas covered: This review focuses on the current status of human chlamydial vaccine research, specifically the potential of biodegradable polymeric nanovaccines to provide efficacious Chlamydia vaccines in the near future. Expert commentary: The safety of biodegradable polymeric nanoparticles-based experimental vaccines with or without adjuvants and the array of available chlamydial vaccine candidates would suggest that clinical trials in humans may be imminent. Also, the promising results from vaccine testing in animal models could lead to human vaccines against trachoma and reproductive disease simultaneously.

    • Injury and Violence
      1. Surveillance for violent deaths -National Violent Death Reporting System, 18 States, 2014External
        Fowler KA, Jack SP, Lyons BH, Betz CJ, Petrosky E.
        MMWR Surveill Summ. 2018 Feb 2;67(2):1-36.

        PROBLEM/CONDITION: In 2014, approximately 59,000 persons died in the United States as a result of violence-related injuries. This report summarizes data from CDC’s National Violent Death Reporting System (NVDRS) regarding violent deaths from 18 U.S. states for 2014. Results are reported by sex, age group, race/ethnicity, marital status, location of injury, method of injury, circumstances of injury, and other selected characteristics. REPORTING PERIOD COVERED: 2014. DESCRIPTION OF SYSTEM: NVDRS collects data from participating states regarding violent deaths. Data are obtained from death certificates, coroner/medical examiner reports, law enforcement reports, and secondary sources (e.g., child fatality review team data, supplemental homicide reports, hospital data, and crime laboratory data). This report includes data from 18 states that collected statewide data for 2014 (Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts, Michigan, New Jersey, New Mexico, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin). NVDRS collates documents for each death and links deaths that are related (e.g., multiple homicides, a homicide followed by a suicide, or multiple suicides) into a single incident. RESULTS: For 2014, a total of 22,098 fatal incidents involving 22,618 deaths were captured by NVDRS in the 18 states included in this report. The majority of deaths were suicides (65.6%), followed by homicides (22.5%), deaths of undetermined intent (10.0%), deaths involving legal intervention (1.3%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force, excluding legal executions), and unintentional firearm deaths (<1%). The term “legal intervention” is a classification incorporated into the International Classification of Diseases, Tenth Revision (ICD-10) and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement. Suicides occurred at higher rates among males, non-Hispanic American Indian/Alaska Natives (AI/AN), non-Hispanic whites, persons aged 45-54 years, and males aged >/=75 years. Suicides were preceded primarily by a mental health, intimate partner, substance abuse, or physical health problem or a crisis during the previous or upcoming 2 weeks. Homicide rates were higher among males and persons aged <1 year and 15-44 years; rates were highest among non-Hispanic black and AI/AN males. Homicides primarily were precipitated by arguments and interpersonal conflicts, occurrence in conjunction with another crime, or related to intimate partner violence (particularly for females). When the relationship between a homicide victim and a suspected perpetrator was known, it was most often either an acquaintance/friend or an intimate partner. Legal intervention death rates were highest among males and persons aged 20-44 years; rates were highest among non-Hispanic black males and Hispanic males. Precipitating factors for the majority of legal intervention deaths were alleged criminal activity in progress, the victim reportedly using a weapon in the incident, a mental health or substance abuse problem, an argument or conflict, or a recent crisis. Deaths of undetermined intent occurred more frequently among males, particularly non-Hispanic black and AI/AN males, and persons aged 30-54 years. Substance abuse, mental health problems, physical health problems, and a recent crisis were the most common circumstances preceding deaths of undetermined intent. Unintentional firearm deaths were more frequent among males, non-Hispanic whites, and persons aged 10-24 years; these deaths most often occurred while the shooter was playing with a firearm and were most often precipitated by a person unintentionally pulling the trigger or mistakenly thinking the firearm was unloaded. INTERPRETATION: This report provides a detailed summary of data from NVDRS for 2014. The results indicate that violent deaths resulting from self-inflicted or interpersonal violence disproportionately affected persons aged <65 years, males, and certain minority populations. The primary precipitating factors for homicides and suicides were intimate partner problems, interpersonal conflicts, mental health and substance abuse problems, and recent crises. PUBLIC HEALTH ACTION: NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in the development, implementation, and evaluation of programs and policies to reduce and prevent violent deaths. For example, North Carolina VDRS data were used to improve case ascertainment of pregnancy-associated suicides, Wisconsin VDRS data were used to develop the statewide suicide prevention strategy, and Colorado VDRS data were used to develop programs and prevention strategies for suicide among veterans. The continued development and expansion of NVDRS to include all U.S. states, territories, and the District of Columbia are essential to public health efforts to reduce the impact of violence.

    • Laboratory Sciences
      1. The measurement of serum and red blood cell folate, two commonly used biomarkers of folate status in populations, is complicated by analytical and data interpretation challenges. Folate results show poor comparability across laboratories, even using the same analytical technique. The folate microbiologic assay produces accurate results and requires simple instrumentation. Thus, it could be set up and maintained in low- and middle-income country laboratories. However, the assay has to be harmonized through the use of common critical reagents (e.g., microorganism and folate calibrator) in order to produce comparable results across laboratories and over time, so that the same cutoff values can be applied across surveys. There is a limited need for blood folate measurements in a country owing to the periodic nature of surveys. Having a network of regional resource laboratories proficient in conducting the folate microbiologic assay and willing and able to perform service work for other countries will be the most efficient way to create an infrastructure wherein qualified laboratories produce reliable blood folate data. Continuous participation of these laboratories in a certification program can verify and document their proficiency. If the resource laboratories conduct the work on a fee-for-service basis, they could become self-sustaining in the long run.

    • Maternal and Child Health
      1. Diagnosis and management of Duchenne muscular dystrophy, part 2: Respiratory, cardiac, bone health, and orthopaedic managementExternal
        Birnkrant DJ, Bushby K, Bann CM, Alman BA, Apkon SD, Blackwell A, Case LE, Cripe L, Hadjiyannakis S, Olson AK, Sheehan DW, Bolen J, Weber DR, Ward LM.
        Lancet Neurol. 2018 .

        A coordinated, multidisciplinary approach to care is essential for optimum management of the primary manifestations and secondary complications of Duchenne muscular dystrophy (DMD). Contemporary care has been shaped by the availability of more sensitive diagnostic techniques and the earlier use of therapeutic interventions, which have the potential to improve patients’ duration and quality of life. In part 2 of this update of the DMD care considerations, we present the latest recommendations for respiratory, cardiac, bone health and osteoporosis, and orthopaedic and surgical management for boys and men with DMD. Additionally, we provide guidance on cardiac management for female carriers of a disease-causing mutation. The new care considerations acknowledge the effects of long-term glucocorticoid use on the natural history of DMD, and the need for care guidance across the lifespan as patients live longer. The management of DMD looks set to change substantially as new genetic and molecular therapies become available.

      2. Diagnosis and management of Duchenne muscular dystrophy, part 1: Diagnosis, and neuromuscular, rehabilitation, endocrine, and gastrointestinal and nutritional managementExternal
        Birnkrant DJ, Bushby K, Bann CM, Apkon SD, Blackwell A, Brumbaugh D, Case LE, Clemens PR, Hadjiyannakis S, Pandya S, Street N, Tomezsko J, Wagner KR, Ward LM, Weber DR.
        Lancet Neurol. 2018 .

        Since the publication of the Duchenne muscular dystrophy (DMD) care considerations in 2010, multidisciplinary care of this severe, progressive neuromuscular disease has evolved. In conjunction with improved patient survival, a shift to more anticipatory diagnostic and therapeutic strategies has occurred, with a renewed focus on patient quality of life. In 2014, a steering committee of experts from a wide range of disciplines was established to update the 2010 DMD care considerations, with the goal of improving patient care. The new care considerations aim to address the needs of patients with prolonged survival, to provide guidance on advances in assessments and interventions, and to consider the implications of emerging genetic and molecular therapies for DMD. The committee identified 11 topics to be included in the update, eight of which were addressed in the original care considerations. The three new topics are primary care and emergency management, endocrine management, and transitions of care across the lifespan. In part 1 of this three-part update, we present care considerations for diagnosis of DMD and neuromuscular, rehabilitation, endocrine (growth, puberty, and adrenal insufficiency), and gastrointestinal (including nutrition and dysphagia) management.

      3. Cost and cost-effectiveness assessments of newborn screening for critical congenital heart disease using pulse oximetry: A reviewExternal
        Grosse SD, Peterson C, Abouk R, Glidewell J, Oster ME.
        Int J Neonatal Screen. 2017 ;3(4):34.

        Screening newborns for critical congenital heart disease (CCHD) using pulse oximetry is recommended to allow for the prompt diagnosis and prevention of life-threatening crises. The present review summarizes and critiques six previously published estimates of the costs or cost-effectiveness of CCHD screening from the United Kingdom, United States, and China. Several elements that affect CCHD screening costs were assessed in varying numbers of studies, including screening staff time, instrumentation, and consumables, as well as costs of diagnosis and treatment. A previous US study that used conservative assumptions suggested that CCHD screening is likely to be considered cost-effective from the healthcare sector perspective. Newly available estimates of avoided infant CCHD deaths in several US states that implemented mandatory CCHD screening policies during 2011-2013 suggest a substantially larger reduction in deaths than was projected in the previous US cost-effectiveness analysis. Taking into account these new estimates, we estimate that cost per life-year gained could be as low as USD 12,000. However, that estimate does not take into account future costs of health care and education for surviving children with CCHD nor the costs incurred by health departments to support and monitor CCHD screening policies and programs.

      4. The National Network of State Perinatal Quality Collaboratives: A growing movement to improve maternal and infant healthExternal
        Henderson ZT, Ernst K, Simpson KR, Berns SD, Suchdev DB, Main E, McCaffrey M, Lee K, Rouse TB, Olson CK.
        J Womens Health (Larchmt). 2018 Feb 1.

        State Perinatal Quality Collaboratives (PQCs) are networks of multidisciplinary teams working to improve maternal and infant health outcomes. To address the shared needs across state PQCs and enable collaboration, Centers for Disease Control and Prevention, in partnership with March of Dimes and perinatal quality improvement experts from across the country, supported the development and launch of the National Network of PQCs National Network of Perinatal Quality Collaboratives (NNPQC). This process included assessing the status of PQCs in this country and identifying the needs and resources that would be most useful to support PQC development. National representatives from 48 states gathered for the first meeting of the NNPQC to share best practices for making measurable improvements in maternal and infant health. The number of state PQCs has grown considerably over the past decade, with an active PQC or a PQC in development in almost every state. However, PQCs have some common challenges that need to be addressed. After its successful launch, the NNPQC is positioned to ensure that every state PQC has access to key tools and resources that build capacity to actively improve maternal and infant health outcomes and healthcare quality.

      5. Longitudinal study of bladder continence in patients with spina bifida in the National Spina Bifida Patient RegistryExternal
        Liu T, Ouyang L, Thibadeau J, Wiener JS, Routh JC, Castillo H, Castillo J, Freeman KA, Sawin KJ, Smith K, Van Speybroeck A, Valdez R.
        J Urol. 2017 Nov 11.

        PURPOSE: Achieving bladder continence in individuals with spina bifida is a lifetime management goal. We investigated bladder continence status through time and factors associated with this status in patients with spina bifida. MATERIALS AND METHODS: We used National Spina Bifida Patient Registry data collected from 2009 through 2015 and applied generalized estimating equation models to analyze factors associated with bladder continence status. RESULTS: This analysis included 5,250 participants with spina bifida in a large, multi-institutional patient registry who accounted for 12,740 annual clinic visit records during the study period. At last followup mean age was 16.6 years, 22.4% of participants had undergone bladder continence surgery, 92.6% used some form of bladder management and 45.8% reported bladder continence. In a multivariable regression model the likelihood of bladder continence was significantly greater in those who were older, were female, were nonHispanic white, had a nonmyelomeningocele diagnosis, had a lower level of lesion, had a higher mobility level and had private insurance. Continence surgery history and current management were also associated with continence independent of all other factors (adjusted OR and 95% CI 1.9, 1.7-2.1 and 3.8, 3.2-4.6, respectively). The association between bladder management and continence was stronger for those with a myelomeningocele diagnosis (adjusted OR 4.6) than with nonmyelomeningocele (adjusted OR 2.8). CONCLUSIONS: In addition to demographic, social and clinical factors, surgical intervention and bladder management are significantly and independently associated with bladder continence status in individuals with spina bifida. The association between bladder management and continence is stronger in those with myelomeningocele.

      6. During gestation, the immune response of the placenta to viruses and other pathogens plays an important role in determining a pregnant woman’s vulnerability toward infectious diseases. Located at the maternal- fetal interface, trophoblast cells serve to minimize the spread of viruses between the host and developing fetus through an intricate system of innate antiviral immune signaling. Adverse pregnancy outcomes, ranging from learning disabilities to preterm birth and fetal death, are all documented results of a viral breach in the placental barrier. Viral infections during pregnancy can also be spread through blood and vaginal secretions, and during the post-natal period, via breast milk. Thus, even in the absence of vertical transmission of viral infection to the fetus, maternal health can still be compromised and threaten the pregnancy. The most common viral DNA isolates found in gestation are adenovirus, cytomegalovirus, and enterovirus. However, with the recent pandemic of Ebola virus, and the first documented case of a neonate to survive due to experimental therapies in 2017, it is becoming increasingly apparent that the changing roles and impacts of viral infection during pregnancy needs to be better understood, while strategies to minimize adverse pregnancy outcomes need to be identified. This review focuses on the adverse impacts of viral infection during gestation, with an emphasis on Ebola virus.

      7. Associations between parental broader autism phenotype and child autism spectrum disorder phenotype in the Study to Explore Early DevelopmentExternal
        Rubenstein E, Wiggins LD, Schieve LA, Bradley C, DiGuiseppi C, Moody E, Pandey J, Pretzel RE, Howard AG, Olshan AF, Pence BW, Daniels J.
        Autism. 2018 Jan 1:1362361317753563.

        The autism spectrum disorder phenotype varies by social and communication ability and co-occurring developmental, behavioral, and medical conditions. Etiology is also diverse, with myriad potential genetic origins and environmental risk factors. Examining the influence of parental broader autism phenotype-a set of sub-clinical characteristics of autism spectrum disorder-on child autism spectrum disorder phenotypes may help reduce heterogeneity in potential genetic predisposition for autism spectrum disorder. We assessed the associations between parental broader autism phenotype and child phenotype among children of age 30-68 months enrolled in the Study to Explore Early Development (N = 707). Child autism spectrum disorder phenotype was defined by a replication of latent classes derived from multiple developmental and behavioral measures: Mild Language Delay with Cognitive Rigidity, Mild Language and Motor Delay with Dysregulation (e.g. anxiety/depression), General Developmental Delay, and Significant Developmental Delay with Repetitive Motor Behaviors. Scores on the Social Responsiveness Scale-Adult measured parent broader autism phenotype. Broader autism phenotype in at least one parent was associated with a child having increased odds of being classified as mild language and motor delay with dysregulation compared to significant developmental delay with repetitive motor behaviors (odds ratio: 2.44; 95% confidence interval: 1.16, 5.09). Children of parents with broader autism phenotype were more likely to have a phenotype qualitatively similar to broader autism phenotype presentation; this may have implications for etiologic research.

    • Mining
      1. CFD gas distribution analysis for different continuous-miner scrubber redirection configurationsExternal
        Zheng Y, Organiscak JA, Zhou L, Beck TW, Rider JP.
        Trans Soc Min Metall Explor Inc. 2017 ;342(1):15-21.

        The U.S. National Institute for Occupational Safety and Health (NIOSH)’s Pittsburgh Mining Research Division (PMRD) recently developed a series of models using computational fluid dynamics (CFD) to study gas distribution around a continuous mining machine with various fan-powered flooded bed scrubber discharge configurations in an exhaust curtain working face. CFD models utilizing species transport model without reactions in FLUENT were constructed to evaluate the redirection of scrubber discharge toward the mining face rather than behind the return curtain. The study illustrates the gas distribution in the slab (second) cut. The following scenarios are considered in this study: 100 percent of the discharge redirected back toward the face on the off-curtain side; 100 percent of the discharge redirected back toward the face, but divided equally to both sides; and 15 percent of the discharge redirected toward the face on the off-curtain side, with 85 percent directed toward the return curtain. These models are compared against a model with a conventional scrubber discharge where air is directed away from the face into the return. The models were validated against experimental data, proving to accurately predict sulfur hexafluoride (SF6) gas levels at four gas monitoring locations. This study includes a predictive simulation examining a 45 degrees scrubber angle compared with the 23 degrees angle for the 100 percent redirected, equally divided case. This paper describes the validation of the CFD models based on experimental data of the gas distribution results.

    • Nutritional Sciences
      1. OBJECTIVE: Differences in bottled v. tap water intake may provide insights into health disparities, like risk of dental caries and inadequate hydration. We examined differences in plain, tap and bottled water consumption among US adults by sociodemographic characteristics. DESIGN: Cross-sectional analysis. We used 24 h dietary recall data to test differences in percentage consuming the water sources and mean intake between groups using Wald tests and multiple logistic and linear regression models. SETTING: National Health and Nutrition Examination Survey (NHANES), 2007-2014. SUBJECTS: A nationally representative sample of 20 676 adults aged >/=20 years. RESULTS: In 2011-2014, 81.4 (se 0.6) % of adults drank plain water (sum of tap and bottled), 55.2 (se 1.4) % drank tap water and 33.4 (se 1.4) % drank bottled water on a given day. Adjusting for covariates, non-Hispanic (NH) Black and Hispanic adults had 0.44 (95 % CI 0.37, 0.53) and 0.55 (95 % CI 0.45, 0.66) times the odds of consuming tap water, and consumed B=-330 (se 45) ml and B=-180 (se 45) ml less tap water than NH White adults, respectively. NH Black, Hispanic and adults born outside the fifty US states or Washington, DC had 2.20 (95 % CI 1.79, 2.69), 2.37 (95 % CI 1.91, 2.94) and 1.46 (95 % CI 1.19, 1.79) times the odds of consuming bottled water than their NH White and US-born counterparts. In 2007-2010, water filtration was associated with higher odds of drinking plain and tap water. CONCLUSIONS: While most US adults consumed plain water, the source (i.e. tap or bottled) and amount differed by race/Hispanic origin, nativity status and education. Water filters may increase tap water consumption.

    • Occupational Safety and Health
      1. BACKGROUND: Toluene Diisocyanate (TDI) is a known respiratory sensitizer linked to occupational asthma (OA). To better manage worker risks, an appropriate characterization of the TDI-OA dose-risk relationship is needed. METHODS: The literature was reviewed for data suitable for dose-response modeling. Previous study data were fit to models to derive prospective occupational exposure limits (OELs), using benchmark dose (BMD) and low-dose extrapolation approaches. RESULTS: Data on eight TDI-exposed populations were suitable for analysis. There were 118 OA cases in a population contributing 13 590 person-years. The BMD-based OEL was 0.4 ppb. The OEL based on low-dose extrapolation to working lifetime extra risk of 1/1000 was 0.3 ppb. CONCLUSIONS: This study synthesized epidemiologic data to characterize the TDI-OA dose-risk relationship. This approach yielded prospective OEL estimates below recent recommendations by the American Conference of Governmental Industrial Hygienists, but given significant study limitations, this should be interpreted with caution. Confirmatory research is needed.

      2. Fatal work-related falls in the United States, 2003-2014External
        Socias-Morales CM, Chaumont Menendez CK, Marsh SM.
        Am J Ind Med. 2018 Jan 30.

        BACKGROUND: Falls are the second leading cause of work-related fatalities among US workers. We describe fatal work-related falls from 2003 to 2014, including demographic, work, and injury event characteristics, and changes in rates over time. METHODS: We identified fatal falls from the Bureau of Labor Statistics (BLS), Census of Fatal Occupational Injuries and estimated rates using the BLS Current Population Survey. RESULTS: From 2003 to 2014, there were 8880 fatal work-related falls, at an annual rate of 5.5 per million FTE. Rates increased with age. Occupations with the highest rates included construction/extraction (42.2 per million FTE) and installation/maintenance/repair (12.5 per million FTE). Falls to a lower level represented the majority (n = 7521, 85%) compared to falls on the same level (n = 1128, 13%). CONCLUSIONS: Falls are a persistent source of work-related fatalities. Fall prevention should continue to focus on regulation adherence, Prevention through Design, improving fall protection, training, fostering partnerships, and increasing communication.

      3. Powered hand tools have become essential to a range of industrial operations since Samuel Ingersoll invented the pneumatic drill in 1871. However, progress often comes with risk. Potential hazards associated with hand-held powered tool use include noise, hand-arm vibration, and a range of ergonomic stresses and physical safety hazards. Acute physical injuries from failure or misuse of the control or trigger mechanism are a particular concern, especially for products such as nail guns. At the same time, many companies using power tools fail to employ a process management approach to selection, procurement, and maintenance, or to educate users of these tools. This often results in unnecessary exposures to noise, vibration, and other physical hazards, as well as impaired productivity and quality. Because few purchasing groups are trained in safety, they are unlikely to consider the hazards and lifecycle costs associated with operating power tools. Efforts to promote purchasing of tools with lower lifecycle costs have failed due to a lack of regulatory criteria, misguided pressure to purchase the tools with the lowest initial costs, and poor understanding of hazardous exposures. Concurrently, safety and health professionals have often failed to influence the purchasing process. A purchasing and process management standard was needed to correct these failings and to stimulate the market conditions for manufacturing and purchasing of power tools that optimize productivity and minimize lifecycle costs. This article outlines a process management approach to the purchase of powered hand-held tools promoted in SAE International Standard AS6228, “Safety Requirements for Procurement, Maintenance and Use of Hand-held Powered Tools.”

    • Parasitic Diseases
      1. The emergence and spread of kelch 13 mutations associated with artemisinin resistance in Plasmodium falciparum parasites in twelve Thai provinces from 2007 – 2016External
        Kobasa T, Talundzic E, Sug-Aram R, Boondat P, Goldman IF, Lucchi NW, Dharmarak P, Sintasath D, Fukuda M, Whistler T, MacArthur J, Udhayakumar V, Prempree P, Chinanonwait N.
        Antimicrob Agents Chemother. 2018 Jan 29.

        Artemisinin-based combination therapy (ACT) is the most effective and widely used treatment for uncomplicated Plasmodium falciparum (Pf) malaria and is a cornerstone for malaria control and prevention globally. Resistance to artemisinin derivatives has been confirmed in the Greater Mekong Subregion (GMS), which manifest as slow parasite clearance in patients and reduced ring-stage susceptibility to artemisinins in survival assays. The Pf kelch 13 gene mutations associated with artemisinin resistant parasites are now wide-spread in the GMS. We genotyped 277 samples collected during an observational study from 2012-2016 from eight provinces in Thailand to identify Pf kelch 13 mutations. The results were combined with previously reported genotyping results from Thailand to construct a map illustrating the evolution of Pf kelch 13 mutations from 2007 – 2016 in the country. Different mutant alleles were found in strains with different geographical origins. The artemisinin resistant Y493H and R539T mutations were detected mainly in eastern Thailand (bordering Cambodia), while P574L was only found in western Thailand and R561H in northwestern Thailand. The C580Y mutation was found across the entire country and was nearing fixation along the Thai-Cambodia border. Overall the prevalence of artemisinin resistant mutations increased over the last ten years across Thailand, especially along the Thai-Cambodia border. Molecular surveillance and therapeutic efficacy monitoring should be intensified in the region to further assess the extent and spread of artemisinin resistance.

    • Reproductive Health
      1. Referral practices among U.S. publicly funded health centers that offer family planning servicesExternal
        Carter MW, Robbins CL, Gavin L, Moskosky S.
        J Womens Health (Larchmt). 2018 Jan 29.

        BACKGROUND: Referrals to other medical services are central to healthcare, including family planning service providers; however, little information exists on the nature of referral practices among health centers that offer family planning. MATERIALS AND METHODS: We used a nationally representative survey of administrators from 1,615 publicly funded health centers that offered family planning in 2013-14 to describe the use of six referral practices. We focused on associations between various health center characteristics and frequent use of three active referral practices. RESULTS: In the prior 3 months, a majority of health centers (73%) frequently asked clients about referrals at clients’ next visit. Under half (43%) reported frequently following up with referral sources to find out if their clients had been seen. A third (32%) of all health centers reported frequently using three active referral practices. In adjusted analysis, Planned Parenthood clinics (adjusted odds ratio 0.55) and hospital-based clinics (AOR 0.39) had lower odds of using the three active referral practices compared with health departments, and Title X funding status was not associated with the outcome. The outcome was positively associated with serving rural areas (AOR 1.39), having a larger client volume (AOR 3.16), being a part of an insurance network (AOR 1.42), and using electronic health records (AOR 1.62). CONCLUSIONS: Publicly funded family planning providers were heavily engaged in referrals. Specific referral practices varied widely and by type of care. More assessment of these and other aspects of referral systems and practices is needed to better characterize the quality of care.

      2. A systematic review and meta-analysis of venous thrombosis risk among users of combined oral contraceptionExternal
        Dragoman MV, Tepper NK, Fu R, Curtis KM, Chou R, Gaffield ME.
        Int J Gynaecol Obstet. 2018 Feb 1.

        BACKGROUND: Combined oral contraceptives (COCs) containing various progestogens could be associated with differential risks for venous thromboembolism (VTE). OBJECTIVE: To evaluate the comparative risks of VTE associated with the use of low-dose (less than 50 mug ethinyl estradiol) COCs containing different progestogens. SEARCH STRATEGY: PubMed and the Cochrane Library were searched from database inception through September 15, 2016, by combining search terms for oral contraception and venous thrombosis. SELECTION CRITERIA: Studies reporting VTE risk estimates among healthy users of progestogen-containing low-dose COCs were included. DATA COLLECTION AND ANALYSIS: A random-effects model was used to generate pooled adjusted risk ratios and 95% confidence intervals; subgroup and sensitivity analyses assessed the impact of monophasic-COC use and study-level characteristics. MAIN RESULTS: There were 22 articles included in the analysis. The use of COCs containing cyproterone acetate, desogestrel, drospirenone, or gestodene was associated with a significantly increased risk of VTE compared with the use of levonorgestrel-containing COCs (pooled risk ratios 1.5-2.0). The analysis restricted to monophasic COC formulations with 30 mug of ethinyl estradiol yielded similar findings. After adjustment for study characteristics, the risk estimates were slightly attenuated. CONCLUSIONS: Compared with the use of levonorgestrel-containing COCs, the use of COCs containing other progestogens could be associated with a small increase in risk for VTE. This article is protected by copyright. All rights reserved.

    • Substance Use and Abuse
      1. Nearly all adult smokers first try cigarettes before age 18 years (1), and adolescents can show symptoms of nicotine dependence within days to weeks of the onset of occasional cigarette smoking (2). Having a usual cigarette brand among adolescent smokers could reflect exposure and receptivity to pro-tobacco advertising and tobacco product appeal (1). To identify usual cigarette brands smoked among U.S. middle and high school students who were current (past 30-day) cigarette smokers, CDC analyzed data from the 2012-2016 National Youth Tobacco Survey (NYTS). Marlboro, Newport, and Camel were the most commonly reported brands smoked during 2012-2016; in 2016, these three were the brands usually smoked for 73.1% and 78.7% of current cigarette smokers in middle and high school, respectively. These three brands also were the three most commonly identified as having a “favorite cigarette ad” in 2012. Efforts to reduce youth exposure to pro-tobacco advertising could help reduce youth smoking (1,3).

    • Zoonotic and Vectorborne Diseases
      1. Investigation of an isolated case of human Crimean-Congo hemorrhagic fever in Central Uganda, 2015External
        Balinandi S, Patel K, Ojwang J, Kyondo J, Mulei S, Tumusiime A, Lubwama B, Nyakarahuka L, Klena J, Lutwama J, Stroher U, Nichol ST, Shoemaker T.
        Int J Infect Dis. 2018 Jan 27.

        BACKGROUND: Crimean-Congo hemorrhagic fever (CCHF) is the most geographically widespread tick-borne viral infection. Outbreaks of CCHF in sub-Saharan Africa are largely undetected and thus under-reported. On November 9, 2015, the National Viral Hemorrhagic Fever Laboratory at the Uganda Virus Research Institute received an alert for a suspect VHF case in a 33-year-old male who presented with VHF compatible signs and symptoms at Mengo Hospital in Kampala. METHODS: A blood sample from the suspect patient was tested by RT-PCR for CCHF and found positive. Serological testing on sequential blood specimens collected from this patient showed increasing anti-CCHFV IgM antibody titers, confirming recent infection. Repeat sampling of the confirmed case post recovery showed high titers for anti-CCHFV-specific IgG. An epidemiological outbreak investigation was initiated following the initial RT-PCR positive detection to identify any additional suspect cases. RESULTS: Only a single acute case of CCHF was detected from this outbreak. No additional acute CCHF cases were identified following field investigations. Environmental investigations collected 53 tick samples, with only 1, a Boophilus decoloratus, having detectable CCHFV RNA by RT-PCR. Full-length genomic sequencing on a viral isolate from the index human case showed the virus to be related to the DRC (Africa 2) lineage. CONCLUSIONS: This is the fourth confirmed CCHF outbreak in Uganda within 2 years after more than 50 years of no reported human CCHF cases in this country. Our investigations reaffirm the endemicity of CCHFV in Uganda, and shows that exposure to ticks poses a significant risk for human infection. These findings also reflect the importance of having an established national VHF surveillance system and diagnostic capacity in a developing country like Uganda, in order to identify the first cases of VHF outbreaks and rapidly respond to reduce secondary cases. Additional efforts should focus on implementing effective tick control methods and investigating the circulation of CCHFV throughout the country.

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CDC Science Clips Production Staff

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DISCLAIMER: Articles listed in the CDC Science Clips are selected by the Stephen B. Thacker CDC Library to provide current awareness of the public health literature. An article’s inclusion does not necessarily represent the views of the Centers for Disease Control and Prevention nor does it imply endorsement of the article’s methods or findings. CDC and DHHS assume no responsibility for the factual accuracy of the items presented. The selection, omission, or content of items does not imply any endorsement or other position taken by CDC or DHHS. Opinion, findings and conclusions expressed by the original authors of items included in the Clips, or persons quoted therein, are strictly their own and are in no way meant to represent the opinion or views of CDC or DHHS. References to publications, news sources, and non-CDC Websites are provided solely for informational purposes and do not imply endorsement by CDC or DHHS.

Page last reviewed: January 31, 2019